Primary Vascular Access: How can we do better?

The long-term survival and quality of life of patients on haemodialysis is dependent on the adequacy of dialysis via an appropriately placed vascular access. The native arteriovenous fistula at the wrist is generally accepted as the vascular access of choice in haemodialysis patients due to its low complication and high patency rates. It has been shown beyond doubt that an optimally functioning arteriovenous fistula is a good prognostic factor of patient morbidity and mortality in the dialysis phase. Recent clinical practice guidelines recommend the creation of a vascular access (native fistula or synthetic graft) before the start of chronic haemodialysis therapy to prevent the need for complication-prone dialysis catheters. A multidisciplinary approach, including nephrologists, surgeons, interventional radiologists and nurses, should improve the haemodialysis outcome by promoting the use of native arteriovenous fistulae. An important additional component of this program is the Doppler ultrasound for preoperative vascular mapping. This approach may be realized without unsuccessful surgical explorations, with a minimal early failure rate and a high maturation, even in risk groups such as elderly and diabetic patients. Vascular access care is responsible for a significant proportion of health care costs in the first year of haemodialysis. These results also support clinical practice guidelines which recommend the preferential placement of a native fistula.